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Military Leads in Treating Traumatic Brain Injury, Expert Says

By Terri Moon CronkAmerican Forces Press Service

BETHESDA, Md., Aug. 31, 2012  The proper management of traumatic brain injuries has become a military medical standard of care that’s returning 95 percent of service members with mild TBI back to the field within five days, said an Army neurologist who served on a Joint Chiefs of Staff panel to develop the protocol.

Army (Dr.) Col. Geoffrey Ling, program manager at the Defense Advanced Research Projects Agency, addressed medical care providers Aug. 27 on the military’s model approach to TBI in a lecture at the National Intrepid Center of Excellence on the campus of Walter Reed National Military Medical Center, here.

Ling, who retires today, has served in Iraq and Afghanistan, and as both a professor and interim chairman of neurology at the Uniformed Services University of the Health Sciences and director of neurocritical care at Walter Reed. He also is an attending neurocritical care physician at Johns Hopkins Hospital in Baltimore, and has a doctorate in pharmacology.

TBI is considered a signature wound of the wars in Iraq and Afghanistan. With the adversity of war and the incidence of TBI, Ling said, the opportunity arose to do something about it.

“We’ve developed a system of care to identify that this was a very important disease, and to learn how to properly manage it,” Ling said. “That required a system from point of entry all the way through rehabilitation, [requiring] a standard, evidence-based approach, and the military created that.”

While military doctors often seek standards of care from the civilian sector, protocol for treating brain injuries was not available, he said.

By developing the TBI system of care, military medicine has created a model for civilians, Ling said, adding that he wants private medical institutions to learn about the military’s approach.

Today, after three or four years of study, which Ling calls “a remarkable achievement,” military doctors to leaders in the field are educated in TBI and know that early screening is critical to diagnose and treat the disease from mild to severe cases, he said. The diagnostic procedure used is called “MACE” -- the Military Acute Concussion Evaluation.

Ling pointed out that renowned teaching medical centers around the country do not have concussion centers, but military posts in war zones do.

“If you go to Kandahar, Bagram … or Herat and ask where the concussion center is, someone will point to it,” he said.

Following the JCS’ “Gray Team” panel’s conclusions, TBI screening became mandatory for what Ling called the “at-risk population” of personnel. The military published and issued manuals that dictate the standards of care, he said.

Making TBI assessments mandatory “obligates” military leaders in the field to make sure troops exposed to a blast or a similar incident are screened because “patients don’t always know they’re hurt with this disease,” Ling said.

The military’s system of care is not necessarily a “magic bullet,” but the strides it has made are greater than that, he said.

“More importantly, it’s identifying TBI as a very important disease and learning how to go about properly managing it,” Ling said.

Recognizing the potential for a TBI begins in the field with the buddy system, Ling said. If a service member suspects a buddy might have had a mild concussion, he said, it’s immediately brought to the attention of military leaders and medical personnel and the assessment begins.

Once a doctor makes a diagnosis, patients with TBI go into a concussion restoration center at the front, Ling said.

And regardless of the degree of injury, all TBI patients go through the same standardized treatment program. Neurosurgeons, he added, also have certain standardized surgical techniques.

“Everybody has to do things in a prescribed way, based upon the best clinical practices, [which] we have,” he added.

The quick-to-react attention has had overwhelming results for patients with mild TBIs, Ling pointed out.

“They’re going back to duty in a very effective, combat-ready way,” he said, “which means fully restored, by doing simple things up front. If you take care of something quickly, it will stay small. But if you let it fester, it gets worse.”

Those service members who don’t recover as quickly undergo further treatment and 90 percent of the time are returned to duty within a couple of weeks, he added.

The remaining group of patients that don’t return to duty have likely “fallen out” because of post-traumatic stress disorder symptoms, Ling said, adding that’s when psychiatrists and social workers get onboard.

“Who would have known unless we did this?” Ling said of the military’s standard of TBI care.

“We want to know what’s wrong with our soldiers so we can take care of them,” he said.